Addressing Safety, Quality, and Cost of Care Through a Telehealth Outpatient Transitional Care Model: Protocol for a Pragmatic Randomized Controlled Trial

Abstract

People with multimorbidity have complex health care needs, resulting in high health service use, hospital readmission rates, and support needs. To prevent unnecessary hospital readmissions, effective coordination during the transition from hospital to primary care is essential; the transitional care model (TCM) is an effective approach to achieve this. This study will adapt the TCM, focusing on a nurse-led telehealth-based follow-up transition coordination service to enhance continuity between hospital and primary care, aiming to reduce unnecessary hospital readmissions and improve patient transitions.